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Cimbak N, Buchmiller TL. Long-term follow-up of patients with congenital diaphragmatic hernia. World J Pediatr Surg 2024; 7:e000758. [PMID: 38618013 PMCID: PMC11015326 DOI: 10.1136/wjps-2023-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/28/2024] [Indexed: 04/16/2024] Open
Abstract
Neonates with congenital diaphragmatic hernia encounter a number of surgical and medical morbidities that persist into adulthood. As mortality improves for this population, these survivors warrant specialized follow-up for their unique disease-specific morbidities. Multidisciplinary congenital diaphragmatic hernia clinics are best positioned to address these complex long-term morbidities, provide long-term research outcomes, and help inform standardization of best practices in this cohort of patients. This review outlines long-term morbidities experienced by congenital diaphragmatic hernia survivors that can be addressed in a comprehensive follow-up clinic.
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Affiliation(s)
- Nicole Cimbak
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Terry L Buchmiller
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
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Masahata K, Nagata K, Terui K, Kondo T, Ebanks AH, Harting MT, Buchmiller TL, Sato Y, Okuyama H, Usui N. Risk Factors for Preoperative Pneumothorax in Neonates With Isolated Left-Sided Congenital Diaphragmatic Hernia: An International Cohort Study. J Pediatr Surg 2024:S0022-3468(24)00048-4. [PMID: 38388286 DOI: 10.1016/j.jpedsurg.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/30/2023] [Accepted: 01/19/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND We aimed to investigate the clinical characteristics and outcomes of patients with isolated left-sided congenital diaphragmatic hernia (CDH) who developed preoperative pneumothorax and determine its risk factors. METHODS We performed an international cohort study of patients with CDH enrolled in the Congenital Diaphragmatic Hernia Study Group registry between January 2015 and December 2020. The main outcomes assessed included survival to hospital discharge and preoperative pneumothorax development. The cumulative incidence of pneumothorax was estimated by the Gray test. The Fine and Gray competing risk regression model was used to identify the risk factors for pneumothorax. RESULTS Data for 2858 neonates with isolated left-sided CDH were extracted; 224 (7.8%) developed preoperative pneumothorax. Among patients with a large diaphragmatic defect, those with pneumothorax had a significantly lower rate of survival to discharge than did those without. The competing risks model demonstrated that a patent ductus arteriosus with a right-to-left shunt flow after birth (hazard ratio [HR]: 1.78; 95% confidence interval [CI]: 1.21-2.63; p = 0.003) and large defects (HR: 1.65; 95% CI: 1.13-2.42; p = 0.01) were associated with an increased risk of preoperative pneumothorax. Significant differences were observed in the cumulative incidence of pneumothorax depending on defect size and shunt direction (p < 0.001). CONCLUSIONS Pneumothorax is a significant preoperative complication associated with increased mortality in neonates with CDH, particularly in cases with large defects. Large diaphragmatic defects and persistent pulmonary hypertension were found to be risk factors for preoperative pneumothorax development. LEVEL OF EVIDENCE LEVEL Ⅲ Retrospective Comparative Study.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan; Department of Pediatric Surgery, Aizenbashi Hospital, Osaka, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takuya Kondo
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan.
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Smithers CJ, Zalieckas JM, Rice-Townsend SE, Kamran A, Zurakowski D, Buchmiller TL. The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk. J Pediatr Surg 2023; 58:1656-1662. [PMID: 36709093 DOI: 10.1016/j.jpedsurg.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/11/2022] [Accepted: 12/25/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion. METHODS A retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression. RESULTS 102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48-39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20-85) vs. those who did not (median 9 mg/dL, IQR 7-13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737). CONCLUSION We demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO. LEVEL OF EVIDENCE Level III cohort study.
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Affiliation(s)
- C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, United States.
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA 98105, United States
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
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Parekh S, Ochotny R, Lazow SP, Ben-Ishay O, Aribindi V, Pluchinotta FR, Tworetzky W, Buchmiller TL, Peyvandi S, Moon-Grady AJ. High prevalence of left superior vena cava and congenital heart disease in patients with pre- and postnatally diagnosed esophageal atresia/tracheoesophageal fistula. Ultrasound Obstet Gynecol 2023; 62:439-440. [PMID: 36929674 DOI: 10.1002/uog.26202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Affiliation(s)
- S Parekh
- Division of Pediatric Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - R Ochotny
- Department of Palliative Care, Akron Children's Hospital, Akron, OH, USA
| | - S P Lazow
- Department of Surgery, Boston Children Hospital/Harvard Medical School, Boston, MA, USA
| | - O Ben-Ishay
- Department of General Surgery, Ramban Healthcare Campus, Haifa, Israel
| | - V Aribindi
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - W Tworetzky
- Department of Surgery, Boston Children Hospital/Harvard Medical School, Boston, MA, USA
| | - T L Buchmiller
- Department of Surgery, Boston Children Hospital/Harvard Medical School, Boston, MA, USA
| | - S Peyvandi
- Division of Pediatric Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - A J Moon-Grady
- Division of Pediatric Cardiology, University of California San Francisco, San Francisco, CA, USA
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O'Hara JE, Buchmiller TL, Bechard LJ, Akhondi-Asl A, Visner G, Sheils C, Becker R, Studley M, Lemire L, Mullen MP, Vitali S, Mehta NM, Dickie B, Zalieckas JM, Albert BD. Long-Term Functional Outcomes at 1-Year After Hospital Discharge in Critically Ill Neonates With Congenital Diaphragmatic Hernia. Pediatr Crit Care Med 2023:00130478-990000000-00185. [PMID: 37098788 DOI: 10.1097/pcc.0000000000003249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVES Congenital diaphragmatic hernia (CDH) is a birth defect associated with long-term morbidity. Our objective was to examine longitudinal change in Functional Status Scale (FSS) after hospital discharge in CDH survivors. DESIGN Single-center retrospective cohort study. SETTING Center for comprehensive CDH management at a quaternary, free-standing children's hospital. PATIENTS Infants with Bochdalek CDH were admitted to the ICU between January 2009 and December 2019 and survived until hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred forty-two infants (58% male, mean birth weight 3.08 kg, 80% left-sided defects) met inclusion criteria. Relevant clinical data were extracted from the medical record to calculate FSS (primary outcome) at hospital discharge and three subsequent outpatient follow-up time points. The median (interquartile range [IQR]) FSS score at hospital discharge was 8.0 (7.0-9.0); 39 patients (27.5%) had at least moderate impairment (FSS ≥ 9). Median (IQR) FSS at 0- to 6-month (n = 141), 6- to 12-month (n = 141), and over 12-month (n = 140) follow-up visits were 7.0 (7.0-8.0), 7.0 (6.0-8.0), and 6.0 (6.0-7.0), respectively. Twenty-one patients (15%) had at least moderate impairment at over 12-month follow-up; median composite FSS scores in the over 12-month time point decreased by 2.0 points from hospital discharge. Median feeding domain scores improved by 1.0 (1.0-2.0), whereas other domain scores remained without impairment. Multivariable analysis demonstrated right-sided, C- or D-size defects, extracorporeal membrane oxygenation use, cardiopulmonary resuscitation, and chromosomal anomalies were associated with impairment. CONCLUSIONS The majority of CDH survivors at our center had mild functional status impairment (FSS ≤ 8) at discharge and 1-year follow-up; however, nearly 15% of patients had moderate impairment during this time period. The feeding domain had the highest level of functional impairment. We observed unchanged or improving functional status longitudinally over 1-year follow-up after hospital discharge. Longitudinal outcomes will guide interdisciplinary management strategies in CDH survivors.
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Affiliation(s)
- Jill E O'Hara
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Terry L Buchmiller
- Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Lori J Bechard
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Gary Visner
- Harvard Medical School, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
| | - Catherine Sheils
- Harvard Medical School, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
| | - Ronald Becker
- Harvard Medical School, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Mollie Studley
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Lindsay Lemire
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Mary P Mullen
- Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Sally Vitali
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Nilesh M Mehta
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Belinda Dickie
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Jill M Zalieckas
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Ben D Albert
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
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Wagner R, Amonkar GM, Wang W, Shui JE, Bankoti K, Tse WH, High FA, Zalieckas JM, Buchmiller TL, Zani A, Keijzer R, Donahoe PK, Lerou PH, Ai X. A Tracheal Aspirate-Derived Airway Basal Cell Model Reveals a Proinflammatory Epithelial Defect in Congenital Diaphragmatic Hernia. Am J Respir Crit Care Med 2023; 207:1214-1226. [PMID: 36731066 PMCID: PMC10161756 DOI: 10.1164/rccm.202205-0953oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Congenital diaphragmatic hernia (CDH) is characterized by incomplete closure of the diaphragm and lung hypoplasia. The pathophysiology of lung defects in CDH is poorly understood. OBJECTIVES To establish a translational model of human airway epithelium in CDH for pathogenic investigation and therapeutic testing. METHODS We developed a robust methodology of epithelial progenitor derivation from tracheal aspirates of newborns. Basal stem cells (BSCs) from CDH patients and preterm and term, non-CDH controls were derived and analyzed by bulk RNA-sequencing, ATAC-sequencing, and air-liquid-interface differentiation. Lung sections from fetal human CDH samples and the nitrofen rat model of CDH were subjected to histological assessment of epithelial defects. Therapeutics to restore epithelial differentiation were evaluated in human epithelial cell culture and the nitrofen rat model of CDH. MEASUREMENTS AND MAIN RESULTS Transcriptomic and epigenetic profiling of CDH and control BSCs reveals a proinflammatory signature that is manifested by hyperactive NF-κB and independent of severity and hernia size. In addition, CDH BSCs exhibit defective epithelial differentiation in vitro that recapitulates epithelial phenotypes found in fetal human CDH lung samples and fetal tracheas of the nitrofen rat model of CDH. Furthermore, blockade of NF-κB hyperactivity normalizes epithelial differentiation phenotypes of human CDH BSCs in vitro and in nitrofen rat tracheas in vivo. CONCLUSIONS Our findings have identified an underlying proinflammatory signature and BSC differentiation defects as a potential therapeutic target for airway epithelial defects in CDH.
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Affiliation(s)
| | - Gaurang M Amonkar
- Massachusetts General Hospital, 2348, Neonatology, Boston, Massachusetts, United States
| | - Wei Wang
- Massachusetts General Hospital, 2348, Neonatology, Boston, Massachusetts, United States
| | - Jessica E Shui
- Massachusetts General Hospital, 2348, Neonatology, Boston, Massachusetts, United States
| | - Kamakshi Bankoti
- Massachusetts General Hospital, 2348, Neonatology, Boston, Massachusetts, United States
| | - Wai Hei Tse
- University of Manitoba Faculty of Medicine, 12359, Winnipeg, Manitoba, Canada
| | - Frances A High
- Massachusetts General Hospital, 2348, Pediatric Surgery, Boston, Massachusetts, United States.,Boston Children's Hospital, 1862, Boston, Massachusetts, United States
| | - Jill M Zalieckas
- Children's Hospital Boston Department of Surgery, 483909, Surgery, Boston, Massachusetts, United States
| | | | - Augusto Zani
- The Hospital for Sick Children, 7979, Developmental and Stem Cell Biology Program, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Division of General and Thoracic Surgery, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Department of Surgery, Toronto, Ontario, Canada
| | - Richard Keijzer
- University of Manitoba and Manitoba Institute of Child Health, Surgery, Pediatrics & Child Health, Physiology (adjunct), Winnipeg, Manitoba, Canada
| | - Patricia K Donahoe
- Massachusetts General Hospital, 2348, Pediatric Surgery, Boston, Massachusetts, United States
| | - Paul Hubert Lerou
- Massachusetts General Hospital, 2348, Neonatology, Boston, Massachusetts, United States
| | - Xingbin Ai
- Massachusetts General Hospital, 2348, Neonatology, Boston, Massachusetts, United States;
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Moskowitzova K, Zalieckas JM, Sheils CA, Studley M, Lemire L, Zurakowski D, Buchmiller TL. Impact of bowel rotation and fixation on obstructive complications in congenital diaphragmatic hernia. J Pediatr Surg 2023; 58:209-212. [PMID: 36396471 DOI: 10.1016/j.jpedsurg.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
AIM OF THE STUDY Small bowel obstruction (SBO) is a known complication after congenital diaphragmatic hernia (CDH) repair, which can require surgery and even extensive bowel resection causing short bowel syndrome (SBS). We investigate whether specific bowel rotation and fixation can be used as a predictor for SBO including volvulus. METHODS A retrospective review of 256 CDH survivors following repair from 2003 to 2020 was performed. Operative notes and upper gastrointestinal series (UGI) were screened to determine the rotation and fixation of the bowel. Primary outcomes included SBO occurrence, SBO treated surgically, and volvulus. For statistical analysis Fisher's exact test was utilized. RESULTS Twenty-two (9%) patients presented with SBO and majority, 19 (86%), required surgery. Adhesion were observed in 10 (45%), recurrence in 5 (23%), and extensive volvulus leading to SBS in 3 (14%). Both rotation and fixation were recorded in 117 (46%). Presence of left CDH with malrotation and nonfixation was a significant predictor for SBO requiring surgery (P<0.05 vs all other groups). All 3 patients with extensive volvulus had left CDH with nonfixed bowel (100%), however only 1 had malrotation (33%). CONCLUSIONS Malrotation and nonfixation are associated with increased SBO in CDH. Normal rotation is not protective and patients are still at risk for volvulus resulting in SBS. SBO requiring surgical intervention is common in CDH. Bowel rotation and fixation are important determinants that, should be routinely documented and education about the risk of SBO should be included in family counseling. LEVEL OF EVIDENCE Level IV - Case Series.
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Affiliation(s)
- Kamila Moskowitzova
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Catherine A Sheils
- Division of Pulmonary Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Mollie Studley
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Lindsay Lemire
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.
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Cellini C, Labuz DF, Buchmiller TL. Novel Approach for Laparoscopically Placed Chronic Amniotic Fluid Catheters in Sheep. Fetal Diagn Ther 2021; 48:400-406. [PMID: 33951639 DOI: 10.1159/000515695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 03/08/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Several fetal therapies involve repeated amniotic fluid intervention. We hypothesize that a minimally invasive approach can be used to safely implant an intrauterine catheter infusion system in a fetal ovine model for chronic use during pregnancy. METHOD Five pregnant sheep underwent operation between gestational days 110 and 115 (term 145 days). A Codman® implantable infusion pump was adapted for intrauterine use. The chamber was placed in the maternal flank and the tunneled catheter laparoscopically inserted into the amniotic cavity, secured with a pursestring. Three had an additional uterine anchoring suture. Ewes were sacrificed after natural delivery, and the uterus underwent gross and microscopic analyses. RESULTS There were no maternal mortalities, abortions, or preterm labor. Pumps were accessed and remained functional throughout gestation. Four ewes delivered healthy term lambs; the other delivered twins with failure to progress and demise. On necropsy, catheters secured with an anchoring suture remained in place, while the other 2 dislodged during labor. There was no chorioamnionitis by culture or histology. CONCLUSION Laparoscopically placed intra-amniotic infusion catheters were implanted safely and remained functional until delivery in an ovine model. This novel approach has promise in providing safe, durable amniotic fluid access for the potential treatment of fetal disease.
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Affiliation(s)
- Christina Cellini
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Daniel F Labuz
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Lazow SP, Demehri FR, Buchmiller TL. A novel anorectal malformation variant: Anocutaneous fistula presenting as median raphe abscesses. J Paediatr Child Health 2021; 57:718-720. [PMID: 32584439 DOI: 10.1111/jpc.14952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/06/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Stefanie P Lazow
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA, United States
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA, United States
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10
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Lazow SP, Richman DM, Dionigi B, Staffa SJ, Benson CB, Buchmiller TL. Prenatal Imaging Diagnosis of Suprarenal Lesions. Fetal Diagn Ther 2021; 48:235-242. [PMID: 33730724 DOI: 10.1159/000512689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/28/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prenatal suprarenal lesions represent diverse pathologies. This study investigated prenatal imaging features and regression patterns associated with specific lesion diagnoses. METHODS This is a multicenter retrospective review of fetuses with prenatally diagnosed suprarenal lesions between 2001 and 2019. Prenatal ultrasound and MRI characteristics, postnatal imaging, and clinical course were reviewed. Prenatal imaging findings were compared by the most common diagnoses and regression patterns. RESULTS Forty-four fetuses were prenatally diagnosed with suprarenal lesions. Diagnoses included pulmonary sequestration (n = 12; 27.3%), adrenal hemorrhage (n = 12; 27.3%), upper quadrant cyst (including 2 duplication cysts, 1 splenic cyst, and 3 indeterminate cysts), neuroblastoma (n = 4), adrenal hyperplasia (n = 3), bilateral adrenal calcifications (n = 1), and indeterminate lesions (n = 6). Sequestrations were uniformly left-sided (100 vs. 50%; p = 0.014) and diagnosed earlier in gestation than adrenal hemorrhages (p = 0.025). Sequestrations were also significantly more likely to have a prenatal feeding vessel (p = 0.005), low T1 MRI signal (p = 0.015), and no MRI blood products (p = 0.018) compared to adrenal hemorrhages. When comparing all 44 patients, a prenatal feeding vessel and low T1 signal on prenatal MRI were significantly associated with lesion persistence (p = 0.003; p = 0.044). DISCUSSION/CONCLUSION Imaging findings on prenatal ultrasound and MRI aid in the diagnosis of suprarenal lesions, including differentiating pulmonary sequestrations and adrenal hemorrhages.
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Affiliation(s)
- Stefanie P Lazow
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Danielle M Richman
- Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Beatrice Dionigi
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine Research, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA,
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11
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Dao DT, Patel N, Harting MT, Lally KP, Lally PA, Buchmiller TL. Early Left Ventricular Dysfunction and Severe Pulmonary Hypertension Predict Adverse Outcomes in "Low-Risk" Congenital Diaphragmatic Hernia. Pediatr Crit Care Med 2020; 21:637-646. [PMID: 32168302 PMCID: PMC7335317 DOI: 10.1097/pcc.0000000000002318] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Given significant focus on improving survival for "high-risk" congenital diaphragmatic hernia, there is the potential to overlook the need to identify risk factors for suboptimal outcomes in "low-risk" congenital diaphragmatic hernia cases. We hypothesized that early cardiac dysfunction or severe pulmonary hypertension were predictors of adverse outcomes in this "low-risk" congenital diaphragmatic hernia population. DESIGN This is a retrospective cohort study using data from the Congenital Diaphragmatic Hernia Study Group registry. "Low-risk" congenital diaphragmatic hernia was defined as Congenital Diaphragmatic Hernia Study Group defect size A/B without structural cardiac and chromosomal anomalies. Examined risk factors included left ventricular dysfunction, right ventricular dysfunction, and severe pulmonary hypertension on the first postnatal echocardiogram. The primary outcome was composite adverse events, defined as either death, extracorporeal membrane oxygenation utilization, oxygen requirement on day 30 of life, or hospitalization greater than or equal to 8 weeks. Multivariable adjustment was performed with logistic regression and inverse probability weighting. SETTING Neonatal index hospitalization for congenital diaphragmatic hernia. PATIENTS "Low-risk" congenital diaphragmatic hernia infants born between January 2015 and December 2018. INTERVENTIONS First postnatal echocardiogram performed within 24 hours from birth. MEASUREMENTS AND MAIN RESULTS Seven-hundred seventy-eight patients were identified as "low-risk" congenital diaphragmatic hernia. Left ventricular dysfunction, right ventricular dysfunction, and severe pulmonary hypertension were present in 10.8%, 20.5%, and 57.5%, respectively. The primary outcome occurred in 21.3%. Death occurred in 3.0% and 9.1% used extracorporeal membrane oxygenation. On unadjusted analysis, all three risk factors were associated with the primary outcome. On all multivariable adjustment methods, left ventricular dysfunction and severe pulmonary hypertension remained significant predictors of adverse outcomes while right ventricular dysfunction no longer demonstrated any effect. CONCLUSIONS Early left ventricular dysfunction and severe pulmonary hypertension are independent predictors of adverse outcomes among "low-risk" congenital diaphragmatic hernia infants. Early recognition may lead to interventions that can improve outcome in this at-risk cohort.
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Affiliation(s)
- Duy T. Dao
- Department of Surgery, Boston Children’s Hospital, Boston, MA,Vascular Biology Program, Boston Children’s Hospital, Boston, MA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Matthew T. Harting
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital, Houston, TX
| | - Kevin P. Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital, Houston, TX
| | - Pamela A. Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital, Houston, TX
| | - Terry L. Buchmiller
- Department of Surgery, Boston Children’s Hospital, Boston, MA,Corresponding Author: Terry L. Buchmiller, MD, Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave, Fegan 3, Boston, MA 02115, Phone: 617-355-6019, Fax: 617-730-0477,
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12
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Rohanizadegan M, Tracy S, Galarreta CI, Poorvu T, Buchmiller TL, Bird LM, Estroff JA, Tan WH. Genetic diagnoses and associated anomalies in fetuses prenatally diagnosed with esophageal atresia. Am J Med Genet A 2020; 182:1890-1895. [PMID: 32573094 DOI: 10.1002/ajmg.a.61639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/12/2020] [Accepted: 05/04/2020] [Indexed: 12/28/2022]
Abstract
Esophageal atresia (EA) is a congenital anomaly occurring in 2.3 per 10,000 live births. Due to advances in prenatal imaging, EA is more readily diagnosed, but data on the associated genetic diagnoses, other anomalies, and postnatal outcome for fetuses diagnosed prenatally with EA are scarce. We collected data from two academic medical centers (n = 61). Our data included fetuses with suspected EA on prenatal imaging that was confirmed postnatally and had at least one genetic test. In our cohort of 61 cases, 29 (49%) were born prematurely and 19% of those born alive died in the first 9 years of life. The most commonly associated birth defects were cardiac anomalies (67%) and spine anomalies (50%). A diagnosis was made in 61% of the cases; the most common diagnoses were vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula with esophageal atresia, radial or renal dysplasia, and limb anomalies association (43%, although 12% met only 2 of the criteria), trisomy 21 (5%), and CHARGE syndrome (5%). Our findings suggest that most fetuses with prenatally diagnosed EA have one or more additional major anomaly that warrants a more comprehensive clinical genetics evaluation. Fetuses diagnosed prenatally appear to represent a cohort with a worse outcome.
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Affiliation(s)
- Mersedeh Rohanizadegan
- Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Tracy
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina I Galarreta
- Department of Pediatrics, University of California, San Diego, California, USA
- Division of Genetics/Dysmorphology, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Tabitha Poorvu
- Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Maternal Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Maternal Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lynne M Bird
- Department of Pediatrics, University of California, San Diego, California, USA
- Division of Genetics/Dysmorphology, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Judy A Estroff
- Maternal Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wen-Hann Tan
- Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Dao DT, Kamran A, Wilson JM, Sheils CA, Kharasch VS, Mullen MP, Rice-Townsend SE, Zalieckas JM, Morash D, Studley M, Staffa SJ, Zurakowski D, Becker RE, Smithers CJ, Buchmiller TL. Longitudinal Analysis of Ventilation Perfusion Mismatch in Congenital Diaphragmatic Hernia Survivors. J Pediatr 2020; 219:160-166.e2. [PMID: 31704054 DOI: 10.1016/j.jpeds.2019.09.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/08/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the natural history of pulmonary function for survivors of congenital diaphragmatic hernia (CDH). STUDY DESIGN This was a retrospective cohort study of survivors of CDH born during 1991-2016 and followed at our institution. A generalized linear model was fitted to assess the longitudinal trends of ventilation (V), perfusion (Q), and V/Q mismatch. The association between V/Q ratio and body mass index percentile as well as functional status was also assessed with a generalized linear model. RESULTS During the study period, 212 patients had at least one V/Q study. The average ipsilateral V/Q of the cohort increased over time (P < .01), an effect driven by progressive reduction in relative perfusion (P = .012). A higher V/Q ratio was correlated with lower body mass index percentile (P < .001) and higher probability of poor functional status (New York Heart Association class III or IV) (P = .045). CONCLUSIONS In this cohort of survivors of CDH with more severe disease characteristics, V/Q mismatch worsens over time, primarily because of progressive perfusion deficit of the ipsilateral side. V/Q scans may be useful in identifying patients with CDH who are at risk for poor growth and functional status.
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Affiliation(s)
- Duy T Dao
- Department of Surgery, Boston Children's Hospital, Boston, MA; Vascular Biology Program, Boston Children's Hospital, Boston, MA
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Jay M Wilson
- Department of Pediatric Surgery, McGovern Medical School at UTHealth, Children's Memorial Hermann Hospital, Houston, TX
| | - Catherine A Sheils
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | | | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | | | - Donna Morash
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Mollie Studley
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Boston Children's Hospital, Boston, MA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Boston Children's Hospital, Boston, MA
| | - Ronald E Becker
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
| | - Charles J Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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14
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Cochran ED, Lazow SP, Kim AG, Burkhalter LS, Frost NW, Stitelman D, Davis J, Santiago-Munoz P, Buchmiller TL, Perrone EE, Schindel DT. The in-utero diagnosis of choledochal cyst: can postnatal imaging predict benefit from early surgical intervention? J Matern Fetal Neonatal Med 2020; 35:1070-1074. [PMID: 32188329 DOI: 10.1080/14767058.2020.1742320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Infants prenatally suspected of having a choledochal cyst (CDC) typically undergo ultrasound imaging shortly after birth. This study sought to evaluate features on the initial postnatal ultrasound (IPU) that could identify newborns at risk for early complications.Methods: Following IRB approval, patients from four US fetal centers with prenatal suspicion for CDC and postnatal imaging from 2000 to 2017 were reviewed. Imaging and clinical courses were assessed.Results: Forty-two patients had prenatal ultrasounds suspicious for CDC. Nineteen (45.2%) were excluded due to diagnostic revision (n = 9), cyst resolution (n = 5), lack of IPU measurements (n = 3), or lack of follow-up (n = 2). The 23 remaining patients were included in the study. Of these, five (21.7%) developed symptoms at a median age of 16.5 days (IQR 16-19 days), and 18 (78.3%) remained asymptomatic throughout the first year after birth. Five patients (21.7%) had cysts ≥ 4.5 cm on IPU (Symptomatic: n = 3; Asymptomatic: n = 2). Eighteen patients (78.3%) had cysts < 4.5 cm on IPU (Symptomatic: n = 2; Asymptomatic: n = 16). An IPU cyst size ≥ 4.5 cm was associated with neonatal symptom manifestation (p = 0.048), with 88.9% specificity (95% CI 65.3-98.6%) and 60% sensitivity (95% CI 14.7-94.7%).Conclusions: In newborns with prenatally diagnosed CDC, a cyst size ≥ 4.5 cm on IPU is associated with symptom development during the first month after birth and therefore early cyst excision is recommended.
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Affiliation(s)
- Elizabeth D Cochran
- Children's Health, Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stefanie P Lazow
- Pediatric Surgery, Harvard University Medical Center/Boston Children's Hospital, Boston, MA, USA
| | - Aimee G Kim
- Pediatric Surgery, CS Mott's Children's Hospital, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Lorrie S Burkhalter
- Pediatric Surgery, Harvard University Medical Center/Boston Children's Hospital, Boston, MA, USA
| | - Natalie W Frost
- Children's Health, Neonatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Stitelman
- Pediatric Surgery, Yale University Medical Center, New Haven, CT, USA
| | - James Davis
- Children's Health, Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Terry L Buchmiller
- Pediatric Surgery, Harvard University Medical Center/Boston Children's Hospital, Boston, MA, USA
| | - Erin E Perrone
- Pediatric Surgery, CS Mott's Children's Hospital, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - David T Schindel
- Children's Health, Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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15
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Robson VK, Shieh HF, Wilson JM, Buchmiller TL. Non-operative management of extralobar pulmonary sequestration: a safe alternative to resection? Pediatr Surg Int 2020; 36:325-331. [PMID: 31707604 DOI: 10.1007/s00383-019-04590-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE This retrospective cohort study compares the natural history of patients with extralobar sequestrations (ELS) who do not undergo intervention with those who undergo resection to assess the safety of non-operative management. METHODS 126 patients with pulmonary sequestrations or congenital pulmonary airway malformations born between 1999 and 2016 were identified. 49 patients had ELS on postnatal imaging, but two were excluded for associated congenital diaphragmatic hernia. Demographic and clinical data were retrospectively reviewed, with phone follow-up for non-operative patients with no records for > 1 year. Statistical analysis was by Fisher's exact test or Wilcoxon signed-rank test (two-tailed p < 0.05). RESULTS 40% (19/47) were managed non-operatively and 60% (28/47) underwent resection. Non-operative patients were less likely to have an intrathoracic ELS: 47% (9/19) vs. 75% (21/28), p = 0.07. No symptoms were attributable directly to the ELS. Non-operative patients had median follow-up 3.2 years, during which time 88% (15/17) of ELS decreased in size on serial imaging. For patients who underwent resection, there was 100% concordance between imaging and intraoperative findings. There was no evidence of inflammation, infection or malignancy on final pathology, though 57% (16/28) of resected lesions had foci of non-aerated cysts. CONCLUSIONS Although further longitudinal study is required, this study supports the safety of non-operative ELS management.
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Affiliation(s)
- Victoria K Robson
- Department of Medicine and Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Hester F Shieh
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3rd Floor, Boston, MA, 02115, USA
| | - Jay M Wilson
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3rd Floor, Boston, MA, 02115, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3rd Floor, Boston, MA, 02115, USA.
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16
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Abstract
Survivorship of patients with congenital diaphragmatic hernia (CDH) has created a unique cohort of children, adolescents and adults with complex medical and surgical needs. Morbidities specific to this disease benefit from multi-specialty care, and the long term follow up of these patients offers a tremendous opportunity for research and collaboration. Herein we aim to offer an overview of the challenges that modern CDH survivors face, and include a risk-stratified algorithm as a general guideline for a multi-specialty follow up program.
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Affiliation(s)
- Laura E Hollinger
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 613/CSB 417, Charleston SC 29425, USA.
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17
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Labuz DF, Asch MJ, Buchmiller TL. Use of Cadaveric Skin Graft for Staged Gastroschisis Repair in a Premature Infant. Neonatology 2020; 117:771-775. [PMID: 32927452 DOI: 10.1159/000510270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/12/2020] [Indexed: 11/19/2022]
Abstract
Gastroschisis is a congenital abdominal wall defect that, when simple, has excellent overall outcomes. However, morbidity increases with prematurity. A staged approach to closure is often needed until the infant can tolerate definitive repair. We demonstrate the novel use of cadaveric skin allograft as a defect patch, exploiting a tolerant neonatal immune system for long-term durable coverage. A 580-g, 26-week-gestation boy was born with gastroschisis. Primary closure was not possible, necessitating staged closure. After initial silo placement, neither the fascia nor the skin could be closed. Therefore, cadaveric skin was utilized for coverage: there was 100% take, no wound care needs, and no acute rejection. He was discharged at 4 months tolerating full feeds. At 6 months signs of rejection ultimately manifested, and he underwent uneventful elective graft excision and fascial closure. We offer this as a useful option for management of staged gastroschisis closure in an extremely premature infant.
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Affiliation(s)
- Daniel F Labuz
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Morris J Asch
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA,
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18
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Dao DT, Demehri FR, Barnewolt CE, Buchmiller TL. A new variant of type III jejunoileal atresia. J Pediatr Surg 2019; 54:1257-1260. [PMID: 30827488 PMCID: PMC6545255 DOI: 10.1016/j.jpedsurg.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/30/2019] [Accepted: 02/02/2019] [Indexed: 12/26/2022]
Abstract
Jejunoileal atresia (JIA) is a congenital defect that can result in significant loss of bowel length. The traditional classification of JIA was first proposed by Grosfeld and includes 4 subtypes. Among these, type IIIB, or apple-peel atresia, is characterized by a proximal atretic jejunum and a distal segment of spiraled bowel that terminates at the cecum. Owing to this anatomy, patients with type IIIB JIA are at increased risk for short bowel syndrome and intestinal failure. In this report, we described the case of a neonate with a prenatal diagnosis of JIA. At exploration, she was initially found to have a type IIIB atresia. However, instead of terminating at the cecum, the distal spiraled segment was followed by 75 cm of normal small bowel and mesentery. Surgical correction proceeded with minimal resection and primary anastomosis. She recovered well from this procedure, tolerated full enteral nutrition by mouth, and displayed good weight gain at outpatient follow-up. Owing to the unique anatomy of the gastrointestinal tract in this case report, we propose the addition of a new class of JIA, type IIIC, to better reflect its prognostication and surgical management.
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Affiliation(s)
- Duy T. Dao
- Department of Surgery, Boston Children’s Hospital, Boston, MA,Vascular Biology Program, Boston Children’s Hospital, Boston, MA
| | | | | | - Terry L. Buchmiller
- Department of Surgery, Boston Children’s Hospital, Boston, MA,Corresponding Author: Terry L. Buchmiller, Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave, Fegan 3, Boston, MA 02155, Phone: 617-355-6019, Fax: 617-730-0477,
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19
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Shieh HF, Estroff JA, Barnewolt CE, Zurakowski D, Tan WH, Buchmiller TL. Prenatal imaging throughout gestation in Beckwith-Wiedemann syndrome. Prenat Diagn 2019; 39:792-795. [PMID: 30784096 DOI: 10.1002/pd.5440] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/12/2019] [Accepted: 02/16/2019] [Indexed: 01/21/2023]
Abstract
PURPOSE Prenatal occurrence and timing of appearance of associated features in Beckwith-Wiedemann syndrome (BWS) are unknown. We reviewed our BWS patients with serial fetal imaging and correlated these with postnatal findings. METHODS All BWS patients with fetal ultrasound (US) or magnetic resonance imaging (MRI) from 2000 to 2016 were reviewed to determine the presence of polyhydramnios, placentamegaly, macrosomia, macroglossia, retrognathia, omphalocele, visceromegaly, and hemihypertrophy. These observations were correlated with postnatal findings. Data were analyzed by Mann-Whitney U test. RESULTS Nine BWS patients underwent 42 fetal imaging studies with median of five (range of two to six) studies per patient between 13 and 35 weeks gestation. All prenatal findings were confirmed postnatally with complete concordance. All patients with omphalocele were detected early in gestation but other postnatal findings less predictably so. All omphaloceles were small, and were found significantly earlier in gestation than macrosomia (P = 0.004) and macroglossia (P = 0.012). Visceromegaly and retrognathia were less frequent, with no significant differences in median gestational age from omphalocele when prenatally identified. CONCLUSIONS In BWS, omphalocele is the most common prenatal finding and routinely observed in early gestation with 100% accuracy. Associated findings of macrosomia, macroglossia, visceromegaly, and retrognathia, when present, are detected later in gestation. Imaging in later gestation may reveal additional abnormalities that support a BWS diagnosis.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Judy A Estroff
- Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carol E Barnewolt
- Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wen-Hann Tan
- Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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20
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Graham CD, Rodriguez L, Flores A, Nurko S, Buchmiller TL. Primary placement of a skin-level Cecostomy Tube for Antegrade Colonic Enema Administration Using a Modification of the Laparoscopic-Assisted Percutaneous Endoscopic Cecostomy (LAPEC). J Pediatr Surg 2019; 54:486-490. [PMID: 30409477 DOI: 10.1016/j.jpedsurg.2018.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 08/25/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Children failing medical management for severe constipation and/or fecal incontinence may undergo surgical intervention for antegrade enema administration. We present a modification of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure that allows primary placement of a skin-level device. METHODS A single-institution retrospective review was performed from 2009 to 2015. In the modified technique the colonoscope is advanced to the cecum, cecal suspension sutures are placed under laparoscopic visualization, and percutaneous needle puncture of the cecum is performed under direct laparoscopic and endoscopic visualization. A skin-level cecostomy tube is then placed over a guide wire. Patient characteristics and 30-day results were analyzed by Fisher's exact test. RESULTS Fifty-two patients underwent attempted LAPEC. Successful LAPEC using both laparoscopic and endoscopic guidance was achieved in 46 (88.5%). A MIC-KEY device was placed in 38. Corflo PEG tube placement was necessary in 14 due to high BMI (mean 28.4). Colonoscopy failed to reach the cecum in 6 and laparoscopy alone was utilized to achieve successful tube placement. Cecostomy site infections occurred in 3 (5.8%), only in those undergoing PEG placement using a pull technique (p < 0.05). CONCLUSION Primary placement of a skin-level device was successful in the majority of patients undergoing cecostomy tube placement for bowel management utilizing antegrade colonic enemas. This technique avoids a second anesthesia for tube conversion. Visualization via colonoscopy with the use of cecal suspension sutures is recommended. High BMI necessitates initial placement of a PEG tube and complications exclusively occurred in this group. TYPE OF STUDY Clinical. LEVEL OF EVIDENCE IV Case series study.
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Affiliation(s)
- Christopher D Graham
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leonel Rodriguez
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Colorectal Program, Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital
| | - Alejandro Flores
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Colorectal Program, Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital
| | - Samuel Nurko
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Colorectal Program, Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Colorectal Program, Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital.
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21
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Tracy S, Buchmiller TL, Ben-Ishay O, Barnewolt CE, Connolly SA, Zurakowski D, Phelps A, Estroff JA. The Distended Fetal Hypopharynx: A Sensitive and Novel Sign for the Prenatal Diagnosis of Esophageal Atresia. J Pediatr Surg 2018; 53:1137-1141. [PMID: 29622396 DOI: 10.1016/j.jpedsurg.2018.02.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND/PURPOSE Although advances have been made in the prenatal diagnosis of esophageal atresia (EA), most neonates are not identified until after birth. The distended hypopharynx (DHP) has been suggested as a novel prenatal sign for EA. We assess its diagnostic accuracy and predictive value on ultrasound (US) and magnetic resonance imaging (MRI), both alone and in combination with the esophageal pouch (EP) and secondary signs of EA (polyhydramnios and a small or absent fetal stomach). METHODS We retrospectively reviewed fetal US and MRI reports and medical records of 88 pregnant women evaluated for possible EA from 2000 to 2016. Seventy-five had postnatal follow-up that confirmed or disproved the diagnosis of EA and were included in our analysis. RESULTS Seventy-five women had 107 study visits (range 1-4). DHP and/or EP were seen on US and/or MRI in 36% of patients, and 78% of those patients had EA. DHP was 24% more sensitive for EA than EP, while EP was 30% more specific. After 28weeks of gestation, DHP had a predictive accuracy for EA of 0.929 (P=0.001). CONCLUSIONS DHP is a sensitive additional prenatal sign of EA. More accurate diagnosis of EA allows for improved counseling regarding delivery, postnatal evaluation, and surgical correction. TYPE OF STUDY Diagnostic. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sarah Tracy
- Department of Surgery, Boston Children's Hospital, Boston, MA.
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA
| | - Offir Ben-Ishay
- Department of General Surgery, Ramban Health Care Campus, Haifa, Israel
| | - Carol E Barnewolt
- Department of Radiology, Boston Children's Hospital, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA
| | - Susan A Connolly
- Department of Radiology, Boston Children's Hospital, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA
| | | | - Andrew Phelps
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Judy A Estroff
- Department of Radiology, Boston Children's Hospital, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA
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Shieh HF, Barnewolt CE, Wilson JM, Zurakowski D, Connolly SA, Estroff JA, Zalieckas J, Smithers CJ, Buchmiller TL. Percent predicted lung volume changes on fetal magnetic resonance imaging throughout gestation in congenital diaphragmatic hernia. J Pediatr Surg 2017; 52:933-937. [PMID: 28385427 DOI: 10.1016/j.jpedsurg.2017.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/09/2017] [Indexed: 01/08/2023]
Abstract
PURPOSE Percent predicted lung volume (PPLV)<15% on fetal MRI predicts high-risk CDH. Potential changes in PPLV throughout gestation and impact on risk stratification are unknown. We reviewed CDH patients with serial fetal MRIs to follow PPLV and determine correlation with postnatal outcomes. METHODS CDH patients with serial fetal MRIs from 2005 to 2015 were included. We recorded prenatal MRI gestational age (GA) and PPLV, postnatal ECMO use, and survival. Data were analyzed by logistic regression and Fisher's exact test. RESULTS 57 patients had 127 fetal MRI studies. PPLV decreased from mean 25.4% to 19.6% between GA 22.1 and 32.6weeks. A steeper decline in PPLV, regardless of final PPLV, was independently predictive of higher ECMO use (p=0.046) and death (p=0.045). All patients with first PPLV<15% remained high-risk with poor outcomes. Of those with first PPLV>15%, 31% dropped below 15%, having similar ECMO use as the high-risk cohort, but trending toward greater survival (p=0.09). Those with first and final PPLV>15% had significantly less ECMO use (p=0.015) and greater survival (p<0.001) than the high-risk cohort. CONCLUSIONS On average, PPLV decreases throughout gestation in fetuses with CDH. Serial MRI is recommended for those with initial PPLV>15%, as clinical outcomes tend to mirror the lowest PPLV. TYPE OF STUDY Treatment study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Carol E Barnewolt
- Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Jay M Wilson
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Susan A Connolly
- Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Judy A Estroff
- Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Jill Zalieckas
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States.
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Shieh HF, Wilson JM, Sheils CA, Smithers CJ, Kharasch VS, Becker RE, Studley M, Morash D, Buchmiller TL. Does the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure change morbidity outcomes for high-risk congenital diaphragmatic hernia survivors? J Pediatr Surg 2017; 52:22-25. [PMID: 27836357 DOI: 10.1016/j.jpedsurg.2016.10.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/20/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE In high-risk congenital diaphragmatic hernia (CDH), significant barotrauma or death can occur before extracorporeal membrane oxygenation (ECMO) can be initiated. We previously examined ex utero intrapartum treatment (EXIT)-to-ECMO in our most severe CDH patients, but demonstrated no survival advantage. We now report morbidity outcomes in survivors of this high-risk cohort to determine whether EXIT-to-ECMO conferred any benefit. METHODS All CDH survivors with <15% predicted lung volume (PPLV) from September 1999 to December 2010 were included. We recorded prenatal imaging, defect size, and pulmonary, nutritional, cardiac, and neurodevelopmental outcomes. RESULTS Seventeen survivors (8 EXIT-to-ECMO, 9 non-EXIT) had an average PPLV of 11.7%. Eight of 9 non-EXIT received ECMO within 2days. There were no significant defect size differences between groups, mostly left-sided (13/17) and type D (12/17). Average follow-up was 6.7years (0-13years). There were no statistically significant differences in outcomes, including supplemental oxygen, diuretics, gastrostomy, weight-for-age Z scores, fundoplication, pulmonary hypertension, stroke or intracranial hemorrhage rate, CDH recurrence, and reoperation. No survivor in our cohort was neurologically devastated. All had mild motor and/or speech delay, which improved in most. CONCLUSIONS In this pilot series of severe CDH survivors, EXIT-to-ECMO confers neither significant survival nor long-term morbidity benefit. LEVEL OF EVIDENCE Level III treatment study.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay M Wilson
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Catherine A Sheils
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Virginia S Kharasch
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ronald E Becker
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mollie Studley
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Donna Morash
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Wolf LL, Nijagal A, Flores A, Buchmiller TL. Late-onset hypertrophic pyloric stenosis with gastric outlet obstruction: case report and review of the literature. Pediatr Surg Int 2016; 32:1013-6. [PMID: 27506212 DOI: 10.1007/s00383-016-3955-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Abstract
We report late-onset hypertrophic pyloric stenosis in a 17-year-old female. She presented with abdominal pain and an episode of upper gastrointestinal hemorrhage and subsequently developed gastric outlet obstruction. Work-up revealed circumferential pyloric thickening, delayed gastric emptying, and a stenotic, elongated pyloric channel. Biopsies showed benign gastropathy, negative for Helicobacter pylori, without eosinophilic infiltrates. Botulinum toxin injection provided limited relief. Diagnostic laparoscopy confirmed the hypertrophic pylorus and we performed laparoscopic pyloromyotomy. The patient tolerated the procedure well and had complete symptom resolution at 1-year follow-up. Hypertrophic pyloric stenosis is a rare cause of gastric outlet obstruction in adolescents and may be managed successfully with laparoscopic pyloromyotomy.
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Affiliation(s)
- Lindsey L Wolf
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont Street, 4th Floor, Suite 4-020, Boston, MA, 02120, USA.
| | - Amar Nijagal
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Alejandro Flores
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
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Ardestani A, Sheu EG, Nepomnayshy D, Rubin MS, Buchmiller TL, Jaklitsch MT, Tavakkoli A. Surgical skills competitions at ACS chapter meetings can increase resident engagement. Bull Am Coll Surg 2016; 101:44-45. [PMID: 27311235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Brown SD, Donelan K, Martins Y, Sayeed SA, Mitchell C, Buchmiller TL, Burmeister K, Ecker JL. Does professional orientation predict ethical sensitivities? Attitudes of paediatric and obstetric specialists toward fetuses, pregnant women and pregnancy termination. J Med Ethics 2014; 40:117-122. [PMID: 23572566 DOI: 10.1136/medethics-2012-101126] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND To determine (1) whether fetal care paediatric (FCP) and maternal-fetal medicine (MFM) specialists harbour differing attitudes about pregnancy termination for congenital fetal conditions, their perceived responsibilities to pregnant women and fetuses, and the fetus as a patient and (2) whether self-perceived primary responsibilities to fetuses and women and views about the fetus as a patient are associated with attitudes about clinical care. METHODS Mail survey of 434 MFM and FCP specialists (response rates 60.9% and 54.2%, respectively). RESULTS MFMs were more likely than FCPs to disagree with these statements (all p values<0.005): (1) 'the presence of a fetal abnormality is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-78.4% vs 63.5%); (2) 'the effects that a child born with disabilities might have on marital and family relationships is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-80.5% vs 70.2%); and (3) 'the cost of healthcare for the future child is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-73.5% vs 55.9%). 65% MFMs versus 47% FCPs disagreed that their professional responsibility is to focus primarily on fetal well-being (p<0.01). Specialists did not differ regarding the fetus as a separate patient. Responses about self-perceived responsibility to focus on fetal well-being were associated with clinical practice attitudes. CONCLUSIONS Independent of demographic and sociopolitical characteristics, FCPs and MFMs possess divergent ethical sensitivities regarding pregnancy termination, pregnant women and fetuses, which may influence clinical care.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, , Boston, Massachusetts, USA
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27
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Lally KP, Lasky RE, Lally PA, Bagolan P, Davis CF, Frenckner BP, Hirschl RM, Langham MR, Buchmiller TL, Usui N, Tibboel D, Wilson JM. Standardized reporting for congenital diaphragmatic hernia--an international consensus. J Pediatr Surg 2013; 48:2408-15. [PMID: 24314179 DOI: 10.1016/j.jpedsurg.2013.08.014] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 08/26/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal death. A wide spectrum of disease severity and treatment strategies makes comparisons challenging. The objective of this study was to create a standardized reporting system for CDH. METHODS Data were prospectively collected on all live born infants with CDH from 51 centers in 9 countries. Patients who underwent surgical correction had the diaphragmatic defect size graded (A-D) using a standardized system. Other data known to affect outcome were combined to create a usable staging system. The primary outcome was death or hospital discharge. RESULTS A total of 1,975 infants were evaluated. A total of 326 infants were not repaired, and all died. Of the remaining 1,649, the defect was scored in 1,638 patients. A small defect (A) had a high survival, while a large defect was much worse. Cardiac defects significantly worsened outcome. We grouped patients into 6 categories based on defect size with an isolated A defect as stage I. A major cardiac anomaly (+) placed the patient in the next higher stage. Applying this, patient survival is 99% for stage I, 96% stage II, 78% stage III, 58% stage IV, 39% stage V, and 0% for non-repair. CONCLUSIONS The size of the diaphragmatic defect and a severe cardiac anomaly are strongly associated with outcome. Standardizing reporting is imperative in determining optimal outcomes and effective therapies for CDH and could serve as a benchmark for prospective trials.
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Affiliation(s)
- Kevin P Lally
- UT Health Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA.
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Ben-Ishay O, Johnson VM, Wilson JM, Buchmiller TL. Congenital Diaphragmatic Hernia Associated with Esophageal Atresia: Incidence, Outcomes, and Determinants of Mortality. J Am Coll Surg 2013. [PMID: 23177372 DOI: 10.1016/j.jamcollsurg.2012.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Offir Ben-Ishay
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.
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Brown SD, Donelan K, Martins Y, Burmeister K, Buchmiller TL, Sayeed SA, Mitchell C, Ecker JL. Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists. Pediatrics 2012; 130:e1534-40. [PMID: 23129074 DOI: 10.1542/peds.2012-1352] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The expansion of pediatric-based fetal care raises questions regarding pediatric specialists' involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists' attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations. METHODS We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%). RESULTS FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001). CONCLUSIONS Pediatric and obstetric specialists differ considerably regarding pediatric specialists' role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital, Boston, MA 02115, USA.
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30
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Ben-Ishay O, Nicksa GA, Wilson JM, Buchmiller TL. Management of Giant Congenital Pulmonary Airway Malformations Requiring Pneumonectomy. Ann Thorac Surg 2012; 94:1073-8. [DOI: 10.1016/j.athoracsur.2012.05.110] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 05/18/2012] [Accepted: 05/25/2012] [Indexed: 11/29/2022]
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Brown SD, Ecker JL, Ward JR, Halpern EF, Sayeed SA, Buchmiller TL, Mitchell C, Donelan K. Prenatally diagnosed fetal conditions in the age of fetal care: does who counsels matter? Am J Obstet Gynecol 2012; 206:409.e1-11. [PMID: 22340943 DOI: 10.1016/j.ajog.2012.01.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 12/21/2011] [Accepted: 01/19/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVE We sought to characterize practices and attitudes of maternal-fetal medicine (MFM) and fetal care pediatric (FCP) specialists regarding fetal abnormalities. STUDY DESIGN This was a self-administered survey of 434 MFMs and FCPs (response rate: MFM 60.9%; FCP 54.2%). RESULTS For Down syndrome (DS), congenital diaphragmatic hernia (CDH), spina bifida: MFMs were more likely than FCPs to support termination (DS 52% vs 35%, P < .001; CDH 49% vs 36%, P < .001; spina bifida 54% vs 35%, P < .001), and consider offering termination options as highly important (DS 90% vs 70%, P < .001; CDH 88% vs 69%, P < .001; spina bifida 88% vs 70%, P < .001). For DS only, MFMs were less likely than FCPs to think that pediatric specialist consultation should be offered prior to a decision regarding termination (54% vs 75%, P < .001). MFMs reported report higher termination rates among patients only for DS (DS 51% vs 21%, P < .001). CONCLUSION MFM and FCP specialists' counseling attitudes differ for fetal abnormalities.
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Nicksa GA, Yu DC, Kalish BT, Klein JD, Turner CGB, Zurakowski D, Barnewolt CE, Fauza DO, Buchmiller TL. Serial amnioinfusions prevent fetal pulmonary hypoplasia in a large animal model of oligohydramnios. J Pediatr Surg 2011; 46:67-71. [PMID: 21238642 DOI: 10.1016/j.jpedsurg.2010.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 09/30/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Severe neonatal pulmonary hypoplasia incurs mortality rates approaching 71% to 95%. We sought to determine the utility of serial amnioinfusions through a subcutaneously implanted intraamniotic catheter to prevent pulmonary hypoplasia in fetal obstructive uropathy. METHODS Fetal lambs (n = 32) were divided into 3 groups. Group I (n = 12) underwent a sham operation, group II (n = 15) underwent a complete urinary tract obstruction via ligation of the urachus and urethra with a subcutaneous tunneled intraamniotic port-a-cath without amnioinfusions, and group III (n = 5) underwent a creation of a complete urinary tract obstruction with a port-a-cath as described in group II with serial amnioinfusions. Lung tissue was analyzed by lung volume to body weight ratios and stereology. Statistical analysis was performed by analysis of variance and Bonferroni comparisons (P < .05). RESULTS Obstructed fetuses grossly had smaller lungs than treated and control animals. Lung volume to body weight ratios were statistically significant between groups. Airspace fractions were comparable between groups I and III (average = 0.53 and 0.55, respectively), although both were significantly greater than group II (average = 0.48) (P = .049). CONCLUSIONS Serial amnioinfusions through an intraamniotic port-a-cath prevented pulmonary hypoplasia in an ovine model of complete obstructive uropathy. The use of an easily accessible device for amnioinfusions may be a viable option to treat oligohydramnios.
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Affiliation(s)
- Grace A Nicksa
- Department of Surgery, Children's Hospital Boston & Harvard Medical School, Boston, MA 02115, USA.
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Beuling E, Kerkhof IM, Nicksa GA, Giuffrida MJ, Haywood J, de Kerk DJA, Piaseckyj CM, Pu WT, Buchmiller TL, Dawson PA, Krasinski SD. Conditional Gata4 deletion in mice induces bile acid absorption in the proximal small intestine. Gut 2010; 59:888-95. [PMID: 20581237 PMCID: PMC2981798 DOI: 10.1136/gut.2009.204990] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS The transcription factor GATA4 is expressed throughout most of the small intestine except distal ileum, and restricts expression of the apical sodium-dependent bile acid transporter (ASBT), the rate-limiting intestinal bile acid transporter, to distal ileum. The hypothesis was tested that reduction of GATA4 activity in mouse small intestine results in an induction of bile acid transport in proximal small intestine sufficient to restore bile acid absorption and homeostasis after ileocaecal resection (ICR). METHODS Bile acid homeostasis was characterised in non-surgical, sham or ICR mice using two recombinant Gata4 models in which Asbt expression is induced to different levels. RESULTS Reduction of intestinal GATA4 activity resulted in an induction of ASBT expression, bile acid absorption and expression of bile acid-responsive genes in proximal small intestine, and a reduction of luminal bile acids in distal small intestine. While faecal bile acid excretion and bile acid pool size remained unchanged, the bile acid pool became more hydrophilic due to a relative increase in tauro-beta-muricholate absorption. Furthermore, proximal induction of Asbt in both Gata4 mutant models corrected ICR-associated bile acid malabsorption, reversing the decrease in bile acid pool size and increase in faecal bile acid excretion and hepatic cholesterol 7alpha-hydroxylase expression. CONCLUSIONS Reduction of intestinal GATA4 activity induces bile acid absorption in proximal small intestine without inducing major changes in bile acid homeostasis. This induction is sufficient to correct bile acid malabsorption caused by ICR in mice.
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Affiliation(s)
- Eva Beuling
- Division of Gastroenterology and Nutrition, Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Ilona M Kerkhof
- Division of Gastroenterology and Nutrition, Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Grace A Nicksa
- Department of Surgery, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Michael J Giuffrida
- Department of Surgery, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Jamie Haywood
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Daniel J aan de Kerk
- Division of Gastroenterology and Nutrition, Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Christina M Piaseckyj
- Division of Gastroenterology and Nutrition, Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - William T Pu
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Terry L Buchmiller
- Department of Surgery, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Paul A Dawson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen D Krasinski
- Division of Gastroenterology and Nutrition, Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
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Nicksa GA, Yu DC, Curatolo AS, McNeish BL, Barnewolt CE, Valim C, Buchmiller TL, Moses MA, Fauza DO. Prenatal urinary matrix metalloproteinase profiling as a potential diagnostic tool in fetal obstructive uropathy. J Pediatr Surg 2010; 45:70-3. [PMID: 20105582 DOI: 10.1016/j.jpedsurg.2009.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 10/06/2009] [Indexed: 12/01/2022]
Abstract
BACKGROUND/PURPOSE The diagnostic evaluation, patient stratification, and prenatal counseling for congenital obstructive uropathy remain sub-optimal. Matrix metalloproteinase (MMP) expression profiles are emerging as a valuable diagnostic tool in assorted disease processes. We sought to determine whether congenital obstructive uropathy impacts MMP expression in fetal urine. METHODS Fetal lambs (n = 25) were divided in two groups: group I (n = 12) underwent a sham operation and group II (n = 13) underwent creation of a complete urinary tract obstruction. Gelatin zymography panels for 4 MMP species were performed on fetal urine in both groups at comparable times post-operatively. Statistical analysis was by the Fisher's exact test (P < .05). RESULTS Overall fetal survival was 80% (20/25). A variety of significant differences in MMP expression between the two groups were identified. The following profiles were present only in obstructed animals: any MMP other than MMP-2 (P = .029), including any MMP other than 63 kDa and 65 kDa (P = .009); 2 or more MMPs excluding MMP-2s (0.029); and 3 or more MMPs (P = .029). CONCLUSIONS Limited matrix metalloproteinase expression is present in the urine of normal ovine fetuses. Fetal obstructive uropathy impacts urinary MMP expression in various distinguishable patterns. Prenatal urinary MMP profiling may become a practical and valuable diagnostic tool in the evaluation of congenital obstructive uropathy.
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Affiliation(s)
- Grace A Nicksa
- Department of Surgery, Children's Hospital Boston & Harvard Medical School, Boston, MA 02115, USA
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Nicksa GA, Pigula FA, Giuffrida MJ, Buchmiller TL. Removal of a sewing needle from an occult esophageal ingestion in a 9-month-old. J Pediatr Surg 2009; 44:1450-3. [PMID: 19573678 DOI: 10.1016/j.jpedsurg.2009.02.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 02/20/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
Abstract
A healthy 9-month-old boy presented with a 1-month history of cough. A chest x-ray showed a linear metallic foreign body (FB) lying transversely in the posterior mediastinum. Computed tomographic scan confirmed the location and size of the metallic FB and also revealed a large pericardial effusion that was corroborated by echocardiogram. The patient underwent a right thoracotomy revealing a normal esophagus without mediastinitis and a 12-mm needle in the posterior mediastinum embedded in the pericardium with the sharp end abutting the left atrium. The needle was extracted uneventfully, and his postoperative course was unremarkable. The diagnosis and treatment for this case are discussed along with a review of the literature.
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Affiliation(s)
- Grace A Nicksa
- Department of Pediatric Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
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Waters KJ, Levine D, Lee EY, Buonomo C, Buchmiller TL. Segmental dilatation of the ileum: diagnostic clarification by prenatal and postnatal imaging. J Ultrasound Med 2007; 26:1251-6. [PMID: 17715322 DOI: 10.7863/jum.2007.26.9.1251] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Kara J Waters
- Department of Radiology, Maine Medical Center, Portland, Maine, USA
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Kunisaki SM, Barnewolt CE, Estroff JA, Myers LB, Fauza DO, Wilkins-Haug LE, Grable IA, Ringer SA, Benson CB, Nemes LP, Morash D, Buchmiller TL, Wilson JM, Jennings RW. Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia. J Pediatr Surg 2007; 42:98-104; discussion 104-6. [PMID: 17208548 DOI: 10.1016/j.jpedsurg.2006.09.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to determine whether ex utero intrapartum treatment with extracorporeal membrane oxygenation (EXIT to ECMO) is a reasonable approach for managing patients antenatally diagnosed with severe congenital diaphragmatic hernia (CDH). METHODS A 6-year retrospective review was performed on fetuses with severe CDH (liver herniation and a lung/head ratio <1.4, percentage of predicted lung volume <15, and/or congenital heart disease). Fourteen of the patients underwent EXIT with a trial of ventilation. Fetuses with poor preductal oxygen saturations despite mechanical ventilation received ECMO before their delivery. Maternal-fetal outcomes were analyzed. RESULTS There were no maternal-reported complications. Three babies passed the ventilation trial and survived, but 2 of them required ECMO within 48 hours. The remaining 11 fetuses received ECMO before their delivery. Overall survival after EXIT-to-ECMO was 64%. At 1-year follow-up, all survivors had weaned off supplemental oxygen, but 57% required diuretics and/or bronchodilators. CONCLUSION This is the largest reported experience using EXIT to ECMO in the management of severe CDH. The EXIT-to-ECMO procedure is associated with favorable survival rates and acceptable pulmonary morbidity in fetuses expected to have a poor prognosis under conventional management.
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Affiliation(s)
- Shaun M Kunisaki
- Department of Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Abstract
OBJECTIVE The uninterrupted passage of amniotic fluid through the gastrointestinal tract is hypothesized to influence both intestinal and overall fetal somatic development. The effect of in utero esophageal ligation (EL) and therefore the exclusion of AF on somatic growth, small intestinal (SI) morphology and proliferation, and the expression of the glucose transporter sodium-glucose cotransporter 1 (SGLT-1) in both normal and intrauterine growth-retarded (IUGR) fetal rabbits were evaluated. METHODS Thirteen pregnant New Zealand white rabbits underwent surgery on day 24 of their normal 31-day gestation. Ipsilateral normal and IUGR fetuses underwent EL; the contralateral normal and IUGR fetuses underwent cervical exploration only forming 4 study groups (control-normal, control-IUGR, EL-normal and EL-IUGR). Rabbits were killed on day 31. Small intestinal villus height was measured, and epithelial cell proliferation was deter mined by proliferating cell nuclear antigen staining. Sodium-glucose cotransporter 1 messenger RNA (mRNA) and protein expressions were analyzed. Statistical analysis was performed using 2-way analysis of variance. RESULTS Esophageal ligation reduced fetal weight in IUGR by 15% and in normal by 10%. Villus height was significantly reduced in IUGR versus normal in both control and EL (control, P = 0.01; EL, P = 0.05). Intrauterine growth-retarded fetuses had reduced SI proliferation versus normal in both control and EL. Sodium-glucose cotransporter 1 mRNA production in EL fetuses was equal to control fetuses. Esophageal ligation-normal and EL-IUGR fetuses exhibited reduced protein levels and decreased staining for SGLT-1 in villus enterocytes. CONCLUSIONS Amniotic fluid exclusion by in utero EL reduced fetal weight. Small intestinal proliferation was not affected by EL. Although SGLT-1 mRNA and protein were produced in all 4 groups, exposure of the fetal gastrointestinal tract to amniotic fluid appears necessary for proper brush border expression of nutrient transporter proteins.
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Affiliation(s)
- Christina Cellini
- Division of Pediatric Surgery, Children's Hospital of New York Presbyterian-Weill Medical College of Cornell University, New York, NY, USA
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Buchmiller TL. Intercostal lung hernia in a 7-year-old boy. J Pediatr Surg 2005; 40:1508-9. [PMID: 16150363 DOI: 10.1016/j.jpedsurg.2005.05.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
AIM The purpose of the present study was to determine the potential maturational effects of maternal dexamethasone administration on fetal upper gastrointestinal motility. METHODS Nineteen pregnant rabbits were randomized into two groups (DEX and CONT) and studied on either day 24, 27 or 30 of pregnancy (term 31 days). The DEX group received intramuscular dexamethasone (DEX) 2 days before study and the controls received saline. Under ultrasound guidance, a needle was percutaneously inserted into each fetal stomach and fluorescein, labeled with color-coded microspheres, was injected. Two hours later, the length of fluorescein travel throughout the small intestine was measured. The percent motility was calculated by dividing the length of fluorescein travel by the total fetal small intestinal length x 100%. RESULTS All maternal and fetal rabbits survived. On day 24 the length of fluorescein travel and the percent motility of the DEX group were significantly longer than controls. There were no differences on either day 27 or 30. Fetal growth was significantly suppressed by a single course of DEX at all gestational ages. CONCLUSIONS Fetal rabbit gastrointestinal motility is significantly increased after prenatal steroids are given early in the last trimester (day 24 of a 31-day gestation). Although beneficial in end-organ maturation, the timing of prenatal steroid administration is crucial to minimize its potential detrimental effects on fetal somatic growth.
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Affiliation(s)
- Masakatsu Sase
- Division of Pediatric Surgery, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, CA, USA
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Abstract
Many cases of intrauterine growth retardation (IUGR) result from placental insufficiency, but the molecular signals accompanying this event are unknown. Insulin-like growth factor 1 (IGF-1) is a potent mitogen for fetal tissues and is lowered in the serum of human infants with IUGR. The rabbit provides an optimal model for the study of IUGR based on fetal position. To determine if IGF-1 expression is altered in the growth-retarded fetus, this naturally occurring rabbit model of IUGR was used. Four fetal rabbit pairs were harvested on Days 21, 23, 25, 27, 29, and 31 of their normal 31-day gestation; they were identified based on uterine position as normal or growth retarded. Fetal weight was recorded and the serum, amniotic fluid, liver, kidney, and small intestine (SI) were collected. The SI was divided into three equal segments: proximal, middle, and distal. Reverse transcription polymerase chain reaction (RT-PCR) was used to measure IGF-1/beta-actin mRNA densitometric band ratios in all tissues. Radioimmunoassay (RIA) was used to measure IGF-1 protein levels in the serum and amniotic fluid. Statistical analysis was performed using ANOVA and the paired Student's t test. Weights were decreased in fetuses with IUGR at all time points (P < 0.05), further validating this rabbit model in the study of IUGR. Liver, proximal, and distal SI IGF-1 mRNA decreased during late gestation (P < 0.01). Kidney IGF-1 mRNA increased throughout late gestation (P < 0.01). Compared with their normal counterparts, fetuses with IUGR had a trend toward decreased IGF-1 mRNA in the kidney, liver, and SI at all time points, reaching significance in the liver on Day 27 (P = 0.002). Serum IGF-1 decreased throughout gestation in all fetuses (P < 0.05). Compared with normal fetuses, fetuses with IUGR had lower serum IGF-1 at all time points, reaching significance at Day 27 (P = 0.02). Amniotic fluid IGF-1 was lower in fetuses with IUGR than in normal fetuses, though not quite reaching significance. Compared with normal fetuses, growth-retarded fetal rabbits trend toward depressed liver, kidney, and intestinal expression of IGF-1 mRNA and lower serum and amniotic fluid IGF-1 protein. Serum IGF-1 levels correlate with fetal weight change. Further studies and potential manipulation of fetal IGF-1 are warranted to investigate potential prenatal intervention in the treatment of IUGR.
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Affiliation(s)
- A Thakur
- Division of Pediatric Surgery, UCLA School of Medicine, Clinical Health Sciences Building, Room 72-126, Los Angeles, California 90095, USA
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Thakur A, Sase M, Lee JJ, Thakur V, Buchmiller TL. Effect of dexamethasone on insulin-like growth factor-1 expression in a rabbit model of growth retardation. J Pediatr Surg 2000; 35:898-904; discussion 904-5. [PMID: 10873033 DOI: 10.1053/jpsu.2000.6914] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The maternal administration of steroids promotes fetal maturative effects in the gastrointestinal tract. To determine if fetal insulin-like growth factor-1 (IGF-1) expression is altered in response to maternal dexamethasone administration, this rabbit model of intrauterine growth retardation (IUGR) was utilized. METHODS Eight pregnant rabbits received either dexamethasone (Dex 0.1 mg/kg/d intramuscular), or normal saline (Cont) on gestational days 26 and 27. Fetuses were harvested on gestational day 28 or 29 and were identified as favored (Fav) or runt (Runt): DexFav, DexRunt, ContFav, and ContRunt. Fetal weight was recorded and the serum, amniotic fluid, liver, kidney, and small intestine (SI) were collected. Reverse transcription polymerase chain reaction (RT-PCR) was used to measure IGF-1/beta-actin mRNA densitometric band ratios in all tissues. Radioimmunoassay (RIA) was used to measure IGF-1 protein levels in the serum and amniotic fluid. RESULTS Weight was decreased in the Runt fetuses at all time-points (P < .08). The percent weight accretion from day 28 to 29, was greatest in the DexRunt fetus (P < .001), suggesting "catch-up" growth. All Dex fetuses (Fav and Runt) had increased liver and proximal, middle and distal SI IGF-1 mRNA at day 28 and elevated levels in the liver, proximal and distal SI at day 29 compared with control fetuses. The DexRunt fetuses had serum IGF-1 protein surpassing that of the DexFav fetus at day 28. CONCLUSIONS This report provides the first description of maternal steroid administration effecting a marked increase in fetal IGF-1 mRNA expression and IGF-1 protein levels in an in vivo rabbit model of IUGR. The growth-retarded fetus appears to be particularly responsive.
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Affiliation(s)
- A Thakur
- Division of Pediatric Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA
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Abstract
BACKGROUND/PURPOSE Graduates of a university surgical residency program were surveyed to identify the timing of specialty selection and the impact that studying in a research laboratory had on subsequent acceptance into a fellowship program. METHODS Between 1975 and 1990, 86 residents completed general surgery training at UCLA Medical Center. A survey was sent to all graduates to determine the focus of their previous laboratory research and when they selected their eventual surgical specialty. Responses were received from 67 of the 86 graduates (78%). RESULTS Forty-eight of the sixty-seven respondents (72%) took one or more years of surgical research during residency. Postresidency fellowship training was selected by 55 of 67 (82%); 50 applied to fewer than five programs; 49 of 55 (89%) received one of their top three choices. Twenty-seven of the sixty-seven residents pursued an academic career (40%). Residents who performed at least 2 years of research were more likely to become academicians (53%) than residents who did 1 year or less of research (22%). Only 39 of 67 residents (58%) had selected a specialty after 2 years of clinical training; 28 more made the selection after the third clinical year. All residents interested in cardiac surgery (n = 18) or plastic surgery (n = 4) prior to research were accepted into fellowships in those specialities, whereas only 37% of those who had an interest in other fields pursued the same specialty (P < 0.0001). Residents performing research in general surgery (n = 9), surgical oncology (n = 18), cardiac surgery (n = 14), and plastic surgery (n = 3) were more likely to practice in that specialty than those doing research in other specialty laboratories. CONCLUSIONS General surgery residents performing research in a specialty laboratory are likely to pursue fellowship training relating to that field. Those who select a career in cardiac or plastic surgery prior to research are most likely to enter into these fields as their eventual specialty. Residents who perform 2 or more years of laboratory research publish more papers and often pursue an academic career.
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Affiliation(s)
- A Thakur
- Division of Pediatric Surgery, UCLA Medical Center, Los Angeles, CA 90095, USA
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Abstract
The interstitial cells of Cajal complex within the gut wall function as a pacemaker to direct peristalsis. Their neoplastic counterpart is the gastrointestinal pacemaker cell tumor, a spindle and/or epithelioid cell mesenchymal tumor previously known as gastrointestinal stromal tumor or incorrectly called leiomyosarcoma in some cases of older reports. Although numerous cases of gastrointestinal leiomyosarcomas have been documented in the English-language literature, no pediatric case of gastrointestinal stromal tumor or gastrointestinal pacemaker cell tumor has, to our knowledge, been recorded. Herein, we report a case of congenital gastrointestinal pacemaker cell tumor confirmed by immunohistochemistry and electron microscopy in a full-term male newborn.
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Affiliation(s)
- S S Wu
- Department of Pathology, Harbor-UCLA Medical Center, Torrance, Calif, USA
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Abstract
A patient was treated for lobar pneumonia due to coccidioidomycosis. When the pneumonia recurred, the patient was found to have an arteriovenous malformation, which had become infected. Complete resolution was achieved with resection and postoperative amphotericin B therapy.
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Affiliation(s)
- R A Braun
- Department of Surgery, Kaiser-Permanente Medical Care Program, Panorama City, CA 91402, USA
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Buchmiller TL, Shaw KS, Lam ML, Stokes R, Diamond JS, Fonkalsrud EW. Effect of prenatal dexamethasone administration: fetal rabbit intestinal nutrient uptake and disaccharidase development. J Surg Res 1994; 57:274-9. [PMID: 8028335 DOI: 10.1006/jsre.1994.1144] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To examine the effect of prenatal steroids on fetal intestinal maturation, eight pregnant rabbits received either dexamethasone (Dex) or saline (Cont) on Days 25-27 of a 31-day gestation. As the rabbit provides a model of growth retardation based on uterine position, fetuses were identified as favored (Fav) or runt (Runt), generating four study groups: ContFav, ContRunt, DexFav, and DexRunt. On Day 31 the small intestinal uptake of glucose and proline was measured by an everted sleeve technique. Additionally, lactase and maltase activity was determined. Small intestinal length and nutrient uptake was significantly increased in the Dex fetuses. Control runts had a trend to decreased levels of nutrient uptake when compared to their favored counterparts. This trend reversed in the Dex fetuses with runt nutrient uptake surpassing that of the favored fetus. A trend to increased enzyme activity of both lactase and maltase was demonstrated. This report provides the first description of maternal steroid administration causing a marked increase in fetal small intestinal length and glucose and proline absorption in an in vivo model of intrauterine growth retardation.
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Buchmiller TL, Kim CS, Chopourian HL, Fonkalsrud EW. Transamniotic fetal feeding: enhancement of growth in a rabbit model of intrauterine growth retardation. Surgery 1994; 116:36-41. [PMID: 8023266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transamniotic fetal feeding has been proposed as prenatal treatment for intrauterine growth retardation as substrates infused into the amniotic cavity are swallowed and absorbed. The rabbit provides an optimal model of intrauterine growth retardation in that a consistent weight ratio of the runt to the favored fetus is found at term. METHODS Thirty growth-retarded rabbit fetuses underwent transamniotic catheterization in the third trimester with incremental infusion of either dextrose, dextrose plus amino acids, or bovine amniotic fluid. One week later fetal weights were determined. The ipsilateral favored fetus served as an operated, noninfused control. RESULTS Fetuses receiving amniotic fluid showed significantly increased somatic growth when analyzed by absolute body weight and by weight ratio versus control. Increases in the liver, lung, and small intestinal weights of the fetuses receiving amniotic fluid paralleled the overall increase in somatic weight. No differences were found in the dextrose or dextrose plus amino acid-infused groups. CONCLUSIONS The increased amount of ingested amniotic fluid, or fetal "force feeding," appears responsible for enhanced growth because bovine and native rabbit amniotic fluid have only negligible differences. This study provides the first report of successful growth augmentation of a fetal rabbit runt with prenatal transamniotic fetal feeding.
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Affiliation(s)
- T L Buchmiller
- Department of Surgery, University of California at Los Angeles School of Medicine
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Abstract
Infants with gastroschisis (GS) commonly require total parenteral nutrition and prolonged hospitalization because of intestinal dysfunction resulting from dysmotility and/or malabsorption. To investigate prepartum small intestinal (SI) nutrient absorption in GS, a fetal rabbit model was surgically created on gestational day 24 (term, 31 to 33 days) in 11 time-mated New Zealand White does in each left ovarian-end fetus. Each right ovarian-end fetus served as a control (C) and was manipulated only. All does, 10 of 11 GS fetuses (91%), and 8 of 11 C fetuses (73%) survived to gestational day 30. GS fetuses had significantly reduced total body weights, SI weights, and SI lengths compared with C fetuses. Using the everted mucosal sleeve technique, the uptakes of an amino acid (proline) and a sugar (glucose) were determined. The uptakes of proline per milligram SI, proline per centimeter SI, and glucose per milligram SI were significantly impaired in GS fetuses compared with C fetuses (P < .04 by Student's paired t test). The uptake of glucose per centimeter SI was also reduced in GS fetuses, but not significantly. Uptake capacities (a measure of the entire SI's ability to absorb a given nutrient) were significantly reduced in GS fetuses compared with C fetuses (proline, 2,670 +/- 612 nmol/min/entire SI v 6,842 +/- 399 nmol/min/entire SI, P < .008 by Student's paired t test; glucose, 402 +/- 69 nmol/min/entire SI v 950 +/- 103, P < .008 by Student's paired t test).
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Affiliation(s)
- K Shaw
- Department of Surgery, UCLA School of Medicine 90024
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Buchmiller TL, Curr M, Fonkalsrud EW. Assessment of alkaline reflux in children after Nissen fundoplication and pyloroplasty. J Am Coll Surg 1994; 178:1-5. [PMID: 8156109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
During an eight month period, 22 children less than 15 years of age (mean age of three years and seven months) who underwent operative treatment of gastroesophageal reflux (GER) were selected for study. All were symptomatic and unresponsive to medical therapy. Preoperative evaluation included esophageal pH probe monitoring in 18 patients, gastric isotope emptying study in 18 patients and contrast studies of the upper part of the gastrointestinal tract in ten patients. Four children with severe neurologic disorders who required placement of a feeding gastrostomy tube underwent fundoplication without preoperative evaluation. All 22 patients had GER and 14 had documented delayed gastric emptying (greater than 60 percent residual at 90 minutes) on radionuclide scan with appropriate meal for age. Each child underwent Nissen fundoplication and tube gastrostomy. Sixteen patients also had a modified pyloroplasty with a 2.5 to 4.0 centimeter vertical seromuscular incision on the antrum. When the patients achieved a full feeding schedule (postoperative day range three to 21 days, mean of 6.2 days), they were put on a fast for six hours and an aspirate was obtained from the gastrostomy tube. Analysis of pH and bile acid content served as indicators of alkaline reflux. The six children without pyloroplasty served as the control group. Intragastric pH ranged from 1.91 to 7.00 (mean of 3.71) and bile acid content ranged from 4 to 150 micrometers per liter (mean of 62 micrometers per liter). No significant differences were seen between patients with fundoplication alone and those with fundoplication and pyloroplasty (p = 0.97 for pH; p = 0.66 for bile acid content). Two patients with pyloroplasty showed slight elevation of intragastric bile acid content at the upper limits of normal. At follow-up evaluation from nine to 23 months (mean of 18 months), all patients were asymptomatic, with only two showing rare gagging. Additionally, nine patients have had complete resolution of their pulmonary symptoms. No patients demonstrated diarrhea, gas bloat or dumping. Nissen fundoplication combined with a modified pyloroplasty or "antroplasty" for delayed gastric emptying provides excellent clinical results with minimal demonstrable bile acid reflux and no change in intragastric pH at the one and one-half year follow-up evaluation.
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Affiliation(s)
- T L Buchmiller
- Division of Pediatric Surgery, University of California Los Angeles School of Medicine
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Fonkalsrud EW, Buchmiller TL. Reduction of wound infection in high-risk surgical patients. Am Surg 1993; 59:838-41. [PMID: 8256939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
During a 9-year period, 183 consecutive patients underwent total colectomy and the endorectal ileal pull-through procedure (ERIPT) for ulcerative colitis (UC) (n = 156), familial polyposis (n = 25), or Hirschsprung's disease (n = 2). The average age was 29.4 years (range 7.1-59.1 years). All patients with UC were steroid-dependent at the time of operation. Two groups were retrospectively reviewed based on the management of their midline abdominal wounds. Ninety consecutive patients underwent the ERIPT procedure between 1983 and 1987 with stapled skin closure and perioperative intravenous antibiotics (group 1A). Between 1988 and 1992, 93 patients had abdominal wall closure in the same manner, however, the wounds were probed daily in four to six sites for the first five postoperative days with a Q-tip moistened with 2 per cent aqueous mercurachrome solution (group 2A). Approximately four months after ERIPT, ileostomy closure was performed on 176 of the patients, of whom 89 had no wound probing (group 1B), and 87 had probing (group 2B). Following colectomy and the ERIPT procedure, 22/90 group 1A patients (24.4%) and 4/93 group 2A patients (4.3%) developed wound infections. Following ileostomy closure only 3/89 (3.4%) group 1B patients and 1/87 (1.2%) group 2B patients developed wound infections. No group 2A or B patients required wound packing, and none had prolonged hospitalization. In contrast, 17 group 1A patients spent more than 1 extra day of hospitalization (mean 2.8 days) and required wound packing a mean of 22.6 days after hospital discharge. This wound infection rate is significantly lower for group 2A versus 1A patients (P < 0.0001, ANOVA).(ABSTRACT TRUNCATED AT 250 WORDS)
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